Lipase inhibitors for the treatment of pancreatitis and organ failure

ABSTRACT

The present invention relates to methods for treating pancreatitis and/or organ failure comprising administering, to a subject in need of such treatment, an effective amount of a lipase inhibitor. It is based, at least in part, on the discoveries that lipotoxicity contributes to inflammation, multisystem organ failure, necrotic pancreatic acinar cell death and in acute pancreatitis, and that inhibition of lipolysis was able to reduce indices associated with these conditions. Accordingly, in various embodiments, the present invention provides for methods and compositions for limiting lipotoxicity and thereby reducing the likelihood of poor outcomes associated with acute pancreatitis and other severe systemic conditions, especially in obese individuals.

PRIORITY CLAIM

This application is a divisional of U.S. patent application Ser. No.13/447,850, filed on Apr. 16, 2012, and claims priority to U.S.Provisional Application No. 61/476,119, filed on Apr. 15, 2011, thecontents of which are hereby incorporated by reference in theirentireties herein.

GRANT INFORMATION

This invention was made with government support under Grant Number UL 1RR024153 from the National Center for Research Resources, a component ofthe National Institutes of Health and DK092460 from the NationalInstitutes of Health. The government has certain rights in theinvention.

1. INTRODUCTION

The present invention relates to the use of lipase inhibitors for thetreatment of pancreatitis and/or organ failure.

2. BACKGROUND OF THE INVENTION

Obesity is a well documented risk factor for worse outcomes in acutepancreatitis (Martinez, et al., Pancreatology 2006, 6:206-209;Papachristou, et al., Pancreatology 2006, 6:279-285; Sempere, et al.,Pancreatology 2008, 8:257-264; Karimgani, et al., Gastroenterology 1992,103:1636-1640), including the risk of local complications (Tsai C J, DigDis Sci 1998, 43:2251-2254; Funnell, et al., Br J Surg 1993,80:484-486), systemic complications such as the systemic inflammatoryresponse syndrome (SIRS), multisystem organ failure (MSOF) and mortality(Papachristou, et al., Pancreatology 2006, 6:279-285; Karimgani, et al.,Gastroenterology 1992, 103:1636-1640; Funnell, et al., Br J Surg 1993,80:484-486; Johnson, et al., Pancreatology 2004, 4:1-6) and the risk oflocal complications. The sites of visceral fat deposition include themesentery, omentum, liver (Park, et al., J Gastroenterol Hepatol 2008,23:900-907), the pancreas, and the peripancreatic space (Olsen T S, ActaPathol Microbiol Scand A 1978, 86A:367-373; Rosso, et al., JGastrointest Surg 2009, 13:1845-1851; Saisho, et al., Clin Anat 2007,20:933-942; Schmitz, et al., Pathol Res Pract 1981, 173:45-53). It hasbeen suggested that visceral adipose tissue, as measured by waist-to-hipratio and waist circumference above ideal cut-off value, may be agreater risk factor for worse outcomes in acute pancreatitis than totalbody fat (Merv, et al., Pancreatology 2002, 2:543-549; Martinez, et al.,Pancreas 1999, 19:15-20). Mechanisms of this may include an elevatedbaseline proinflammatory state (Ghanim, et al, Circulation 2004,110:1564-1571) and an exaggerated inflammatory response (Sempere, etal., Pancreatology 2008, 8:257-264) associated with obesity. Levels ofproinflammatory cytokines such as Interleukin-1β and tumor necrosisfactor-α are increased in pancreata of obese mice (Mathur, et al.,Nonalcoholic fatty pancreas disease, HPB (Oxford) 2007, 9:312-318).Increased fat accumulation in the pancreas and peripancreatic space hasbeen noted in association with increased body weight (Olsen T S, ActaPathol Microbiol Scand A 1978, 86A:367-373; Saisho, et al., Clin Anat2007, 20:933-942; Schmitz, et al., Pathol Res Pract 1981, 173:45-53).

Intrapancreatic fat has been shown to increase with BMI in studiesevaluating autopsy samples (Olsen T S, Acta Pathol Microbiol Scand A1978, 86A:367-373; Saisho, et al., Clin Anat 2007, 20:933-942; Schmitz,et al., Pathol Res Pract 1981, 173:45-53) surgically resected samples(Rosso, et al., J Gastrointest Surg 2009, 13:1845-1851) and radiologicalappearance of the pancreas (Saisho, et al., Clin Anat 2007, 20:933-942;Matsumoto, et al., Radiology 1995, 194:453-458). The distribution of fatis fairly uniform in the dorsal pancreas and is reduced in the ventralpancreas (Schmitz, et al., Pathol Res Pract 1981, 173:45-53). Unevenfatty replacement in the pancreas is infrequent (3.2%), and the patternof fat distribution is not influenced by obesity (Matsumoto, et al.,Radiology 1995, 194:453-458).

The pancreas produces enzymes that aid in digestion and absorption offood; one such enzyme is lipase, which digests fat. A number ofinhibitors of pancreatic lipase, which can inhibit absorption ofingested fat and thereby reduce caloric intake, have been developed asanti-obesity drugs. Examples of pancreatic lipase inhibitors includeorlistat (marketed as the prescription drug Xenical by Roche and as anover-the-counter drug, Alli, by GlaxoSmithKline), cetilistat, andlipstatin. Orlistat has been reported to promote apoptosis and reducecell grown and lymph node metastasis in a mouse melanoma model (Carvalhoet al., Int. J. Cancer 2008, 123:2557-2565).

3. SUMMARY OF THE INVENTION

The present invention relates to methods and compositions for treatingpancreatitis and/or organ failure comprising administering, to a subjectin need of such treatment, an effective amount of a lipase inhibitor. Itis based, at least in part, on the discoveries that lipotoxicitycontributes to inflammation, multisystem organ failure, necroticpancreatic acinar cell death and in acute pancreatitis, and thatinhibition of lipolysis was able to reduce indices associated with theseconditions. Accordingly, in various embodiments, the present inventionprovides for methods and compositions for limiting lipotoxicity andthereby reducing the likelihood of poor outcomes associated with acutepancreatitis and other severe systemic conditions, especially in obeseindividuals. In certain non-limiting embodiments, the invention providesfor an improved formulation of lipase inhibitor combined with solubilityenhancing agents.

4. BRIEF DESCRIPTION OF THE FIGURES

The patent or application file contains at least one drawing executed incolor. Copies of this patent or patent application publication withcolor drawing(s) will be provided by the Office upon request and paymentof the necessary fee.

FIG. 1A-C. Representative images of pancreatic sections showing amountof intrapancreatic fat as quantified by the pathologist. (A) No fat(0%). The section shows pancreatic tissue with rare adipocytes (lessthan 0.5% fat). This was quantified as 0%. (A′) shows a magnification ofthe area outlined by the box in A. (B): Section showing 10%intrapancreatic fat. (B′) shows the area outlined by the box in B. Notethis is composed of interlobular adipose tissue. (C) Section showing 70%intrapancreatic fat. Note the area of fat is bounded by 2 areas ofpancreatic tissue and thus was included as intrapancreatic fat. (C′)shows a magnification of the boxed area highlighting the presence ofadipose tissue.

FIG. 2: Obese individuals have a higher percentage of intrapancreaticfat irrespective of acute pancreatitis. Graph showing box plots of the %intrapancreatic fat in lean and overweight (BMI<30) and obese (BMI>30)control patients (white boxes, left set) and patients with an autopsydiagnosis of acute pancreatitis (grey boxes, right set). The numbers inparenthesis denote number of patients in each group. The dotted linedepicts the mean. The p value depicts the significance of differencebetween the two groups.

FIG. 3A-C. Intrapancreatic fat increases with BMI in both controls andacute pancreatitis patients. Correlation analysis between BMI andpercent intrapancreatic fat. Each dot represents the value for anindividual patient. (A) Relation in controls r=0.431,p=0.002 (B)Relation in acute pancreatitis patients p r=0.446,p<0.03 (C) Relation inboth controls and acute pancreatitis combined, r=0.445, p<0.001

FIG. 4: Obese patients with acute pancreatitis have similarintrapancreatic fat percentage irrespective of whether it is an autopsydiagnosis or a clinical diagnosis: Comparison of intrapancreatic fatpercentage in lean and obese patients with an autopsy diagnosis of acutepancreatitis (left set, in white) and those with a clinical diagnosis ofacute pancreatitis (right set, in grey). The numbers in parenthesisdenote number of patients in each group. The dotted line depicts themean. As can be seen, obese patients had significantly higher (p<0.01)amounts of intrapancreatic fat in both sets.

FIG. 5A-B. Patients with clinically severe acute pancreatitis havehigher BMIs and intrapancreatic fat. (A) Box plots showing a comparisonof BMIs of patients with clinically mild (left) and severe (right) acutepancreatitis. The BMIs of patients with severe acute pancreatitis weresignificantly higher (p<0.03) than those with mild acute pancreatitis.(B) Box plots showing a comparison of percent intrapancreatic fat ofpatients with clinically mild (left) and severe (right) acutepancreatitis. The intrapancreatic fat percentage of patients with severeacute pancreatitis were significantly higher (p<0.003) than those withmild acute pancreatitis. The numbers in parenthesis denote number ofpatients in each group. The dotted line depicts the mean.

FIG. 6A-G. BMI Increases IPF with high UFAs worsening pancreatic injury:(A) % IPF in controls (white), AP on autopsy (light grey), clinical AP(dark grey) patients with BMI <30 or BMI ≧(first 3 pairs), clinicallymild and severe AP (fourth pair) patients. (B) Non contrast CT(thresholding method) vs. histology % IPF correlation. Humanpancreatitis serial sections stained for calcium (C), H&E (C′) showingfat necrosis (quadrangle), parenchymal injury (dotted polygon) aroundcalcium staining (dashed ovals). Acinar necrosis (D), fat necrosis (E)PFAN box plots (F) in controls, mild (mild) and severe AP. (G) % NEFAsin human pancreatic necrosis debridement fluid, White, black barsrespectively show UFAs and SFAs. Table 1 shows p values.

FIG. 7A-G. Lipolysis of adipocyte triglyceride causes acinar cellnecrosis. Propidium Iodide (PI) uptake in control acini (A), co-culturedwithout (B), m with 50 μM orlistat (Ac+orli), with adipocytes with(Ac.+Ad) or with 50 μM orlistat (Ac+Ad+orli). (F) Cytochrome C (Cyto. C,upper panel) in mitochondrial (M), cytoplasmic (C) fractions of Acinialone, co-cultured without (ac+Ad.) and with 50 μM orlistat(Ac.+Ad.+Orli). Lower panel: Mitochondrial marker COX IV. (G) NEFAconcentration in medium of Acini, adipocytes (Adipo.), co-culturewithout (Acini+Adipo.) or with 50 μM orlistat (Acini+Adipo+Orli).

FIG. 8A-H. UFAs induce acinar necrosis and inflammatory mediatorgeneration: (A) Intra-acinar calcium increase (Cai) with 600 μM fattyacids (LLA: linolenic, LA; Linoleic, OA, Oleic, SA: Stearic, PA;palmitic acid). (B) 1 μM thapsigargin (Thaps.) but not EGTA (1 mM)prevents 600 μM LA induced Cai increase (C) Acinar LDH leakage at 5hours. Complex 1 (D), V(E) activity in control acini (CON), with 300 μMLA or 1200 μM PA. Bar graphs with SEM showing TNF-α (F), CXCLI (G), andCXCL2 (H) mRNAs induced by 200 μM LA, 200 μM PA compared to controls(Con.).

FIG. 9A-G. Lipolysis worsens pancreatic damage in obese mice: (A, A′)Calcium (A), H&E (A′) stained serial sections showing pancreatic fatnecrosis (black, brown in A, blue in A′), surrounding parenchymal injury(pink, blue areas with loss of cellular detail in A, A′ respectively).Dotted area in A; saponified parenchymal fat. Gross images in vehicle(B,C) or orlistat treated animals with pancreatitis (B′, C′), peritonealcavity (C, C′). Note orlistat prevents saponification. Serum calcium(D), pancreatic necrosis (E), fat necrosis (F) PFAN (G) (as % of totalarea), in controls (Con), pancreatitis (IL), vehicle (IL+Veh), orlistat(IL+Orli) treatment. Shown below are p values.

FIG. 10A-M. End-organ damage and mortality in obese mice are preventedby inhibiting lipolysis: (A) % NEFAs in Adipose tissue triglyceride oflean (white bars), obese mice (black bars). (B). Serum UFAs(micromoles/liter) in controls (Con), pancreatitis (IL), vehicle (Veh),pancreatitis with vehicle (IL+Veh), orlistat treatment (IL+Olri). (C)Table showing mortality in ob/ob mice Kidney H&E (D-D3), Oil-red-Ostaining (60×) (E-E3), TUNELS (F-F3) in controls (E, F, J), Pancreatitis(E1, F1, J1), pancreatitis with vehicle (E2, F2, J2), pancreatitis withorlistat treatment (E3, F3, J3). BUN (G), lung section apoptotic count(H), Lung MPO (I), serum adipokines, cytokines (J, K, L., M). Shownbelow are p values.

FIG. 11A-B. Quantification of IPF by CT method 1 and its correlationwith histology. (A) shows representative images of pancreaticattenuation measurement by placing a total of 9 circular regions ofinterests (ROIs; 1 cm in maximum diameter) over the head (n=3), body(n=3), and tail (n=3) of the pancreas and quantifying these asHounsfield units (HU). (B) shows the correlation of the mean pancreaticattenuation (as HUs) with the % IPF on CT scanning for each patient.

FIG. 12A-C. Box plots comparing acinar necrosis (A), fat necrosis (B)and peri-fat acinar necrosis (PFAN) (C) among non-obese non-obese(BMI<30, and obese (BMI≧30) controls and acute pancreatitis patients (APPt.), shown as a percentage of total area. The p value comparing thevarious groups is shown above each graph. The dotted line depicts themean.

FIG. 13A-C. CD68-positive macrophages accumulate around areas ofperi-fat acinar necrosis. Immunostaining for CD68 shows weak positivityin or around non-necrosed fat (A, inset of B). However, thisdramatically increased in areas surrounding fat-necrosis and peri-fatacinar necrosis (PFAN, inset of B and C; arrows point towardCD68-positive cells).

FIG. 14. Schematic showing the setup of the co-culture system andsources used for assays.

FIG. 15A-B. (A): Acinar autophagy is not induced in the co-culture, asevidenced by lack of increase of lipidated form of LC3 (LC3-II) overcontrol levels whether acini (Ac.) are cultured with adipocytes in theabsence (Ac+Ad.) or in the presence of 50 μM orlistat (Ac+Ad+Orli).Chymotrypsin (Chymo.) was used as marker of acinar cells and perilipin(Perilip.) for adipocytes (Ad.). Each marker was present only in theappropriate homogenate signifying lack of contamination by other celltype. (B). There is no increase in active caspase 3 (casp3) over controlacinar levels (Ac.) whether acini (Ac.) are cultured with adipocytes inthe absence (Ac+Ad.) or in the presence of 50 μM orlistat (Ac+Ad+Orli),signifying no evidence of apoptosis.

FIG. 16. Glycerol release, in the medium after 1 hour of adipocyte(Adipo.) culture. The 10 μM isoprotrenol (Isop) stimulated increase inglycerol levels was not significantly prevented by 50 μM orlistat(Orli), supporting its role as a inhibitor of lipases and its lowpermeability through cell membranes.

FIG. 17A-B. (A) Trypan blue uptake in control acini and after co-culturewith adipocytes without (acini+adipocytes) and with 50 μM orlistat(orli). Note the ubiquitous uptake in the absence of orlistat,signifying acinar injury. (B) Whereas acini co-cultured with adipocytesin the absence of orlistat (acini+Adipocytes) exhibit no secretoryresponse under basal conditions (Bas), or in response to physiologic(100 pM) and supraphysiologic (100 nM) doses of caerulein, afterco-culture with adipocytes in the presence of 50 μM orlistat(acini+Adipo+Orli), the acini exhibit an amylase secretory pattern likecontrol acini incubated alone (Acini), signifying retained function. *and ** indicates significant (p<0.05) difference in values compared withbasal and both basal and 100 pM caerulein respectively.

FIG. 18. Inhibition of lipolysis prevents increase in resistin. Resistinlevels measured in the medium harvested after culturing acini alone(Acini), adipocytes alone (Adipo.), and co-culture with adipocytes inthe absence (Acini+Adipo.) or in the presence of 50 μM orlistat(Acini+Adipo+Orli).

FIG. 19A-B Time course of acinar LDH leakage (A) with 300 μM fatty acids(LLA; linolenic acid, LA; Linoleic acid, OA; Oleic acid, SA; Stearicacid, PA; palmitic acid). (B) Dose response of increase in intracellularcalcium levels with different concentrations of linoleic acid added toacinar cells.

FIG. 20A-B. (A) Effect of 30 μM BAPTA on 300 μM linoleic acid (LA)induced LDH leakage at 90 minutes and 3 hours. The significant reductionby BAPTA at these time points could not be sustained over the 5 hours ofthe experiment. EGTA (1 mM) was ineffective in preventing LDH leakage atboth the 90 minute (21.2±8.3%) or at the 3 hour time point (54.6±6.4%,p=0.41). (B) Cytochrome C (Cyto. C, upper panel) in mitochondrial pellet(M), and cytoplasmic supernatant (S) fractions of Acini alone (Acini),Acini after incubation with 300 μM linloleic acid (Acini+LA300) for 90minutes and Acini preincubated with 30 μM BAPTA for 30 minutes flowed byaddition of 300 μM linloleic for 90 minutes (Acini+LA300+BAPTA). Thereduction in cytochrome C leakage into the cytoplasmic supernatant wasnot significantly reduced by BAPTA.

FIG. 21A-C. Complex II (A), IV (B) and citrate synthase (C) activitiesin control acini (CON) acini and those treated with 300 μM LA or 1200μM. There was no significant difference induced by LA or PA comparedwith controls.

FIG. 22A-E. (A) Cytochrome C leakage from the mitochondrial fraction (M)to the cytosolic fraction (C) induced in acini (Ac.) by 300 μM linoleicacid (LA) at 1.5 hours. COX IV was used as mitochondrial loadingcontrol. Autophagy (B) and apoptosis (C) are not activated by 300 μMlinoleic acid (LA) as shown by lack of increase in LC3-II and activecaspase3, respectively. (D) Acinar ATP levels induced by 300 μM linoleicacid (LA) at 5 hours. E: Propidium iodide (PI) uptake induced by 300 μMLinoleic acid (LA) at 5 hours. * indicates a p=0.0000.

FIG. 23A-B. Serum amylase (A) and lipase (B) levels compared betweencontrols (Con), pancreatitis (IL), pancreatitis+vehicle (IL+Veh), andpancreatitis+orli stat (IL+Orli). The p values between different groupsare shown below the graphs. Note orlistat significantly reduced all ofthese compared with IL or IL+Veh groups.

FIG. 24. Serum saturated fatty acid levels (SFA) in controls (Con),pancreatitis (IL), vehicle (Veh), pancreatitis+vehicle (IL+Veh), andpancreatitis+orli stat (IL+Orli). The p values between different groupsare shown above. Orlsitat (IL+Orli) did not significantly reduce the SFAlevels compared with the IL+Veh group.

FIG. 25A-F. (A-D) Electron microscopy images from controls (Control,4400×) (A), pancreatitis, 3400× (B), pancreatitis+vehicle, 3400× (C),and pancreatitis+orlistat, 3400× (D) treated mice showing lipidvacuoles, some of which have dense deposits of calcification (Arrows)and mitochondrial swelling. Orlistat reduces these in the animals withpancreatitis. (E, F) Human kidney serial sections from patient dyingwith acute renal failure resulting from acute pancreatitis showingtubular damage on hematoxylin and eosin (E) and calcification on VonKossas (F).

FIG. 26A-D. Lung TUNELs (40×) in controls (A), ob/ob pancreatitis (B),pancreatitis with vehicle (C), and pancreatitis with orlistat treatment(D).

FIG. 27A-C. Gross pancreatic appearance at the time of necropsy afterintraductal infusion of GTL (A), GTL+orlistat (B), GTL+cetilistat (C).Each image show individual pancreata with the head, duodenal loop in atthe top and the pancreatic tail, with attached spleen at the bottom.Note the extensive hemorrhage and gross evidence of necrosis in panel Aimages. These are absent in panel B, and only present in the last imagein panel C (animal died on day 1).

FIG. 28A-C. TUNEL staining of lung sections. (A) Lung section of a ratdying with GTL induced pancreatitis showing numerous brown stainingTUNEL positive nuclei (arrows). (B): Lung section of a rat administeredGTL with orlistat showing absence of TUNEL positive nuclei. (C): Lungsection of a rat administered GTL with Cetilistat showing absence ofTUNEL positive nuclei.

FIG. 29A-C. TUNEL staining of kidney sections. (A) kidney section of arat dying with GTL induced pancreatitis showing numerous brown stainingTUNEL positive nuclei in the tubules. (B) kidney section of a ratadministered GTL with or (C) kidney section of a rat administered GTLwith cetilistat showing absence of staining TUNEL positive nuclei.listatshowing absence of staining TUNEL positive nuclei.

5. DETAILED DESCRIPTION OF THE INVENTION

The present invention relates to methods and compositions for treatingpancreatitis comprising administering, to a subject in need of suchtreatment, an effective amount of a lipase inhibitor. Effectivetreatment of pancreatitis is indicated by, for example and not by way oflimitation, a decrease in serum level of pancreatic enzyme(s), improvedradiologic findings, and/or a decrease in secondary organ failure,hypocalcaemia and/or systemic inflammation.

Non-limiting embodiments of the invention provide for a method fortreating acute pancreatitis in an obese subject comprisingadministering, to the subject, an effective amount of a pancreaticlipase inhibitor.

A subject may be a human subject or a nonhuman subject, such as, but notlimited to, a dog, cat, horse, cattle, sheep, goat, or rodent.

Non-limiting embodiments of the invention provide for a method ofreducing the risk of organ failure in a subject suffering from acutepancreatitis comprising administering, to the subject, an effectiveamount of a pancreatic lipase inhibitor. Organs for which the risk oforgan failure may be reduced include the kidney (where failure isreferred to as renal failure), the lung (where failure is referred to aspulmonary failure), as well as multisystem organ failure (e.g. multipleorgan dysfunction syndrome involving at least these two organs). Thestatus of these organs may be determined using clinical methods wellknown in the art. For example, and not by way of limitation, kidneyfunction (and the development of renal failure) may be assessed viaincreased blood urea nitrogen levels, increased creatinine, decreasedurine output, and/or histologic findings; lung function and thedevelopment of pulmonary failure may be assessed using pulmonaryfunction tests, blood gases (oxygen and carbon dioxide levels), oxygensupplementation requirements (e.g. nasal cannula or face mask orventilator, with different percentages and flow rates of oxygen) and/orhistologic findings; (for indices of organ failure, see J. Wallach,1978, Interpretation of Diagnostic Tests, Third Edition, Little, Brownand Co., Boston, and/or J. Wallach, 2006, Interpretation of DiagnosticTests, Eighth Edition, Lippincott Williams & Wilkins, both incorporatedby reference in their entireties). Likewise, an index of systemicinflammation is an increase in levels of one or more inflammatorymediators, including but not limited to tumor necrosis factor alpha,monocyte chemotactic protein 1 and/or interleukin 6 These embodimentsare supported, at least in part, by working examples below, which showthe effectiveness of pancreatic lipase inhibitors in decreasing the riskof multisystem organ failure.

In certain non-limiting embodiments of the invention, a pancreaticlipase inhibitor may be administered to the subject intraperitoneally,intravenously, orally, via a sustained release implant, subcutaneously,intramuscularly, or by another route known in the art.

The term “obese” as used herein refers to a subject having a body massindex of greater than 25 and particularly greater than or equal to 30.

Non-limiting embodiments of the invention provide for a method fortreating acute pancreatitis in an obese subject comprisingadministering, to the subject, an effective amount of a pancreaticlipase inhibitor. In certain non-limiting embodiments, suchadministration may be achieved, for example, in the region of thepancreas of the subject, by administering the lipase inhibitorintraperitoneally, for example as a solution or a sustained-releaseimplant, or by another route.

In non-limiting embodiments of the invention, the pancreatic lipaseinhibitor is orlistat or cetilistat. According to certain embodiments ofthe invention orlistat or cetilistat is administered non-orally, forexample by local injection or administration to the region of thepancreas, for example by intraperitoneal infusion. In certainembodiments orlistat or cetilistat may be administered in an alcoholsolution. For example, but not by limitation, where the subject is ahuman the daily dose may be between 1 and 50 mg/kg or between 5 and 20mg/kg, or between 7 and 15 mg/kg or between 3 and 12 mg/kg, or between10 and 15 mg/kg, or between 1 and 5 mg/kg, or about 10 mg/kg, which maybe administered as a single dose or as a divided dose (e.g., twice a day(BID), three times a day (TID) or four times a day (QID)). For example,and not by way of limitation, the daily dose may be administered in adosage regimen for 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15,16, 17, 18, 19, or 20 days. For example, and not by way of limitation,the daily dose may be administered every day, or every other day, orevery third day, or every fourth day, or every fifth day, or every sixthday, or once a week. A dosage regimen may be repeated as clinicallyrequired. A dosage may be administered together with food or other meansof enteral or parenteral nutrition.

Alternative pancreatic lipase inhibitors that may be used according tothe invention include, but are not limited to, lipstatin, panclicins A,B, C, D, or E, CT-II (from an extract of Nomame herba; Yamamoto et al.,2000, Int. J. Obesity 24(6):758-764), and 3-0-tran-p-coumaroyl actinicacid. For example, the dose of an alternative pancreatic lipaseinhibitor may be determined based on the orlistat and cetilistat dosesset forth herein by adjusting the dose based on the relative inhibitorpotency of the compounds.

In certain non-limiting embodiments, the invention provides for animproved formulation of lipase inhibitor combined with solubilityenhancing agents. The lipase inhibitor may be, for example, and not bylimitation, orlistat, cetilistat, or a combination thereof or aderivative of either. Solubility enhancing agents comprise one or moretriglyceride form of a fatty acid and one or more bile salt. Suitablefatty acids (to be used in triglyceride form) include but are notlimited to oleic, linolenic, palmitic, stearic or short chain fattyacids and combinations thereof (for example, a triglyceride where notall the fatty acids linked are the same; mixtures of triglycerides whereall fatty acids linked to a triglyceride are the same; and mixtureswhere some triglycerides comprise the same fatty acid and othertriglycerides comprise more than one species of fatty acid). Suitablebile salts include, but are not limited to, taurocholate, ortaurochenodoxycholic acid (taurochenodoxycholate), taurolitholcholicacids (taurolithocholate), or bile acids like cholic acids lithocholicacid or their glycine conjugates and/or sodium salts thereof, andcombinations thereof. The amount of bile acid administered is sufficientto enhance solubility but insufficient to produce substantial toxiceffect. In certain non-limiting embodiments, the amount of bile acidadministered, when distributed in the total body volume of the subject,approximates physiologic levels, for example, but not limited to, isbetween 0.01 and 10 fold body levels. In certain embodiments of theinvention, a formulation comprises a lipase inhibitor andsolubility-enhancing amounts of a triglyceride form of one or more fattyacids and a bile salt. In certain embodiments, said formulation may beprepared by preparing a first solution comprising a lipase inhibitor anda solubility-enhancing amount of a triglyceride form of one or morefatty acid, with optional gentle warming (for example, heating tobetween about 30-50 degrees Centigrade or to between 35 and 40 degreesCentigrade or to about 40 degrees Centigrade) and then adding a secondsolution comprising a solubility-enhancing amount of a bile salt,followed by mixing, for example, but not limited to, by sonication. In aspecific, non-limiting embodiment, the solution can be prepared asfollows: 75 mg of orlistat is weighed to which 187 microliters ofglyceryl trilinoleate (GTL) is added, and the mixture is gently heatedto for 15-30 seconds, with gentle shaking till clear. 3.75 mgs of sodiumtaurocholate is dissolved in 7.2 ml saline (phosphate buffered, with apH of 7.4) in a separate container. The sodium taurocholate solution isadded gradually in small (about 1 ml) aliquots to the orlistat GTLsolution, and sonicated after the addition of one or each of these toproduce a white solution.

6. EXAMPLE Increased Intrapancreatic Fat is Associated with Obesity andSevere Acute Pancreatitis 6.1 MATERIALS AND METHODS

We searched the University of Pittsburgh Medical Center—PresbyterianHospital autopsy database from 1998 till 2008 and identified allpatients who received a postmortem diagnosis of acute pancreatitis. Thediagnosis of acute pancreatitis in all cases was based on gross andmicroscopic appearance at the time of autopsy. Of the 46 acutepancreatitis patients identified and had pancreas slides available forreview, we excluded the 19 patients in whom the autopsy report alsomentioned a pathologic diagnosis of chronic pancreatitis and twopatients who were post Whipple resection for pancreatic cancer to avoidthe changes that would occur secondary to these pathologies. Anadditional patient with acute pancreatitis whose slides showed severehemorrhage and excessive autolysis was excluded since this would haveprecluded an accurate measurement of amount of fat.

Thus, the total sample size for acute pancreatitis patients was 24. Fromthe remaining patients in the autopsy database, we randomly chose 50subjects as controls for this study.

The slides of all patients and controls were retrieved and reviewed. Thestudy was approved by the Committee for Oversight of Research Involvingthe Dead at the University Of Pittsburgh Medical Center. The electronicclinical records of patients with an autopsy diagnosis of acutepancreatitis were reviewed to assess whether a subject had clinicalcriteria for acute pancreatitis (serum amylase or lipase ≧3 fold upperlimit of normal, typical abdominal pain or radiologic findings tosupport the diagnosis), and to assess the severity acute pancreatitis(defined as presence of single or multisystem organ failure attributableto acute pancreatitis, a mention of necrotizing pancreatitis on computedtomography report, or “widespread”, “extensive” or “diffuse” necrosisnoted at the time of autopsy). Of the 24 patients, thirteen met theclinical criteria for acute pancreatitis. All 13 had a ≧3 fold increasein amylase and/or lipase documented within the week before death. Ofthese 1 patient had all 3 criteria (pain, abnormal CT, increasedenzymes), 7 patients had 2 criteria (abdominal pain and increasedenzymes in 3 patients, and CT abnormalities with increased enzymes in 4patients), 1 had a clinical diagnosis of acute pancreatitis listed onhis hospitalization records, 3 were sedated/comatose on ventilatorsupport when elevated pancreatic enzymes (>3fold increase inamylase/lipase) were documented (last week before death), and in onepatient acute pancreatitis was suspected based solely on elevatedpancreatic enzymes—this patient also had hypercalcemia during hospitaladmission. Of the 13 patients, five had severe acute pancreatitis basedon—local complications (“extensive necrosis” or “severe necrotizingpancreatitis”, “pancreatic hypo perfusion” mentioned on CT scan—3patients or “diffuse” or “extensive” necrosis noted at the time ofautopsy—all 5 patients). Four of these five patients had systemiccomplications of MSOF or acute respiratory distress syndrome attributedto acute pancreatitis.

The remaining 11 patients did not fulfill the clinical criteria foracute pancreatitis. Nine of these did not have serum amylase or lipaseestimation in the 2 weeks prior to death. One patient had a 2 foldelevation three days before death (patient had history of alcohol abuseand cirrhosis) and 1 had normal enzymes 5 days before death. CT abdomenwas done in only one of these 11 patients 9 days before death and wasnormal. Eight of the patients were on ventilator support 5 or more daysbefore death. Of the remaining 3 patients, one had a history of alcoholabuse as described above, one had septic shock and was on the ventilatorfor 3 days prior to death (autopsy revealed focal fat necrosis andmoderate congestion), and one died of cardiogenic shock in a backgroundof systemic lupus erythematosus (autopsy revealed mild acutepancreatitis). In none of these was pancreatitis thought to be animmediate cause of death. In one of the 11 patients, acute pancreatitiswas reported as an underlying cause of death. This patient was statuspost kidney pancreas transplant, was on a ventilator for 20 days and hadpulmonary embolism as the immediate cause of death.

For histologic evaluation, we retrieved all hematoxylin and eosinstained slides of the pancreas (1-4 in number) of control and acutepancreatitis patients. A trained pathologist with specific interest ingastrointestinal pathology blinded to demographic and clinical dataexamined all slides to quantify intrapancreatic fat. Adipose tissue withlarge vessels and nerves not bounded by at least two pieces ofpancreatic parenchyma was regarded as peripancreatic and excluded. Theremaining adipose tissue was measured as a percentage area of eachindividual field. Examples demonstrating various amounts ofintrapancreatic fat in a field are shown in FIG. 1A-F. The percentage ofintrapancreatic fat for each individual field was added. The finalnumber was divided by the number of fields to give a percentageintrapancreatic fat for that section. For patients with more than 1section, the average of the percentage of intrapancreatic fat for allfields from different sections was chosen as representative for thespecimen.

Statistical Analysis:

Continuous data is presented as mean±standard deviation (SD) andcategorical data as proportions. Bivariate comparisons for continuousdata were performed using the Student's t-test or Pearson correlationcoefficient, and categorical data was compared using the chi-squaredtest or Fischer's exact test as applicable. Subjects with a BMI of <30were classified as normal/overweight while those with a BMI of ≧30 wereclassified as obese. We used linear regression analyses to determine thefactors predicting \intrapancreatic fat percentage. In these analyses,we used age (years), BMI (as continuous variable), disease status(control or acute pancreatitis case) as independent variables. Nocollinearity was detected on data analysis. A two-tailed p-value of<0.05 was considered as significant. The data was analyzed using SPSSversion 17 software, Chicago, Ill.

6.2 RESULTS

Obesity is Associated with Increased Intrapancreatic Fat in Controls:

We initially confirmed the findings published in previous studiesshowing a positive association between obesity and intrapancreaticfat10-13. The mean age for controls was 64.2+16.0 years. While 22/50(44%) of the controls were obese (mean BMI 37.4+6.1), the remaining 56%were normal or overweight (mean BMI 24.3+3.7). A significant correlationof intrapancreatic fat was seen with BMI (r=0.431,p=0.002, FIG. 3A) butnot with age (r −0.063, p=0.662). The percentage intrapancreatic fat inobese controls was significantly higher compared to controls who werenormal or overweight (18.3+10.8% vs. 10.3+9.9%; p<0.009) (FIG. 2, whiteboxes).

Obesity is Associated with Increased Intrapancreatic Fat in Acutepancreatitis:

Nine of the 24 patients (38%) with a diagnosis of acute pancreatitiswere normal or overweight (BMI 25.3+1.7) and 15 (62%) were obese (BMI38.2+7.2). The BMI in respective patient groups with acute pancreatitiswas not significantly different from those of the corresponding controlgroups (p=0.62 and p=0.75 respectively). Similar to controls, asignificant correlation for intrapancreatic fat percentage was seen withBMI (r=0.445,p<0.03, FIG. 3B) but not with age (r 0.088, p=0.681) andobese acute pancreatitis patients had significantly higher percentage ofintrapancreatic fat than normal or overweight patients (20.8+7.1% vs.10.9+9.0%,p<0.01, FIG. 2 grey boxes).

Intrapancreatic Fat is Similar in Controls and Acute Pancreatitispatients irrespective of autopsy or clinical diagnosis:

There was no significant difference between controls and acutepancreatitis cases for age, BMI (overall) and intrapancreatic fatpercentage. The correlation between BMI and percent intrapancreatic fatis shown in FIG. 3A-B. The intrapancreatic fat percentage was notsignificantly different in acute pancreatitis patients from the amountsin their respective control groups (p=0.81 and 0.75 for normal oroverweight patients and obese patients respectively). Theintrapancreatic fat in patients with clinical acute pancreatitis wassimilar to those who only had a pathologic diagnosis of acutepancreatitis. This was noted within the groups having a BMI<30 (5.0+4.4%vs. 10.9+9.0% respectively p=0.19) and the ones with a BMI>30 (19.4+9.3%vs. 20.8+7.1%, p=0.77). In addition, the statistically significantdifference between in intrapancreatic fat between patients with BMI<30and those with a BMI>30 was maintained irrespective of whether acutepancreatitis was diagnosed on autopsy or by clinical criteria (FIG. 4).

Intrapancreatic Fat is Higher in Patients with Clinically Severe AcutePancreatitis:

Of the 13 patients with a clinical diagnosis of acute pancreatitis, 5had clinically severe acute pancreatitis while 8 had mild acutepancreatitis. The BMI of the patients with clinically severe acutepancreatitis (40.0+6.4 vs. 30.3+7.1, p=0.03) (FIG. 5A) as well as theamount of intrapancreatic fat (23.4+9.6%. vs 7.9+5.6%, p=0.003) (FIG.5B) was significantly higher compared with those who patients mild acutepancreatitis.

Regression Analysis Reveals BMI as a Determinant for IntrapancreaticFat:

On regression analysis, after controlling for age and disease status(controls vs. acute pancreatitis), a significant positive associationwas seen between increasing BMI and percent intrapancreatic fat(beta-0.46, p<0.001). In this model, no significant association was seenfor intrapancreatic fat with age or disease status.

6.3 DISCUSSION

In this study we have confirmed previous observations that thepercentage of intrapancreatic fat increases with BMI in subjects withoutacute pancreatitis, and extend these findings to patients with acutepancreatitis. In addition, we demonstrate a positive relationshipbetween intrapancreatic fat percentage and the severity of acutepancreatitis. Our observation of an increase in intrapancreatic fat withincreasing BMI in subjects without acute pancreatitis is very similar totwo recent studies (11, 12). Siasho et al evaluated intrapancreatic fatin subjects without pancreatitis using CT scan and autopsy samples. Theycalculated fat amount by studying its differential density compared toacinar tissue in the hand outlined pancreas on CT. They included 47control autopsy patients in whom intrapancreatic fat percentage wascompared with BMI, and noted a similar increase in intrapancreatic fatas we do. They also noted an association between increasingintrapancreatic fat and age up to the 4th decade of adult life whilestudying individuals from birth up to 100 years. 224 of the adults intheir study were less than 40 years of age. This age group is notcommonly affected by pancreatitis (2/24 acute pancreatitis patients and5/50 controls in our study) and was not represented in our study, thuscontributing the lack of association between intrapancreatic fat and agenoted by us. Rosso et al also noted an increase of intrapancreatic fatwith BMI, but reported the amount of intrapancreatic fat in deciles. The4th decile or more (intrapancreatic fat>40%) had a mean BMI of 29.5% 11.Their population of patients, however were post pancreaticoduodenectomyand they did not include patients with acute pancreatitis. A low BMI intheir study may have been associated with a previous history of cancer,since 80 of the 111 patients in their study had a duodenal orpancreatico-biliary malignancy, including 61 patients with pancreaticcancer. To our knowledge, the relationship between intrapancreatic fatand BMI in patients with acute pancreatitis has not been evaluatedpreviously. We demonstrate that this relationship in patients with acutepancreatitis is similar to subjects without acute pancreatitis. We foundthat the intrapancreatic fat percentage in patients with acutepancreatitis was similar to controls—overall or after stratification forBMI. This finding suggests that intrapancreatic fat may not have acausal role in initiating an attack of acute pancreatitis. Of the 13patients with clinical acute pancreatitis in our study, all 5 patientswith severe acute pancreatitis had a BMI of >30. This agrees well withthe several studies that have shown an association between obesity andadverse outcomes in patients with acute pancreatitis (Martinez, et al.,Pancreatology 2006, 6:206-209; Papachristou, et al., Pancreatology 2006,6:279-285; Sempere, et al., Pancreatology 2008, 8:257-264; Karimgani, etal., Gastroenterology 1992, 103:1636-1640). A higher prevalence ofobesity in acute pancreatitis patients postmortem is likely due to ouruse of an autopsy diagnosis of acute pancreatitis which represents ahigher percentage of patients dying with severe disease. Moreover, theassociation between intrapancreatic fat and BMI was significant onlinear regression analysis after controlling for age and disease status(i.e. controls vs. acute pancreatitis). While the association of obesityand worse outcomes of acute pancreatitis has been shown in severalclinical studies ((Martinez, et al., Pancreatology 2006, 6:206-209;Papachristou, et al., Pancreatology 2006, 6:279-285; Sempere, et al.,Pancreatology 2008, 8:257-264; Karimgani, et al., Gastroenterology 1992,103:1636-1640)), the site/s of fat deposition that may be playing acausal role in this has remained unclear. The significant increase inintrapancreatic fat in obese subjects and with severe acute pancreatitissuggests a potential role of intrapancreatic fat with severity in acutepancreatitis. In our study all 5 of the patients with severepancreatitis had “extensive” “diffuse” or “widespread” fat necrosisnoted in the pancreas at the time of autopsy. Likewise studies in ob/obmice have shown these to have a fulminant course with high mortality inresponse to IL-12 and IL-1822. This was associated with severeintrapancreatic fat necrosis, a phenomenon rarely noted in lean mice.Similarly extensive local pancreatic fat necrosis in response to IL-12and IL-18 was noted in mice with diet induced obesity (Pini, et al,Obesity (Silver Spring) 2009). Whether an increase in intrapancreaticfat is associated with worse intrapancreatic fat necrosis, and if fatnecrosis is an innocent bystander or has a pathologic role inpancreatitis remains to be determined. The cause of systemic injury inacute pancreatitis remains unclear. Four of the five patients withsevere acute pancreatitis had ARDS/MSOF attributed to pancreatitis.These systemic complications of acute pancreatitis and associated highermortality have previously been associated with obesity (Papachristou, etal., Pancreatology 2006, 6:279-285; Karimgani, et al., Gastroenterology1992, 103:1636-1640; Funnell, et al., Br J Surg 1993, 80:484-486;Johnson, et al., Pancreatology 2004, 4:1-6). This has been associatedwith increased levels of interleukin-la, IL-1 receptor antagonist,Interleukin-6, Interleukin-8 (Sempere, et al., Pancreatology 2008,8:257-2643). However, whether this is an acute response ofintrapancreatic fat to acute pancreatitis or a greater baselinepro-inflammatory state initiated at other sites of visceral fatdeposition (Ghanim, et al., Circulation 2004, 110:1564-1571) is unknown.A limitation of our study is the use of autopsy samples. However,biopsies are not routinely performed in patients with acutepancreatitis, making this approach impractical and not feasible. Inaddition, loss of tissue planes, edema, necrosis during acutepancreatitis and inability to clearly tell intrapancreatic fromperipancreatic fat could potentially limit the accuracy of radiologictechniques in determining the amount of intrapancreatic fat during acutepancreatitis. Another limitation of our study is the small sample size,especially for patients with a clinical diagnosis of acute pancreatitisbefore death. Despite this we note a significant association betweenintrapancreatic fat amount and BMI with severe acute pancreatitis. Sinceall patients with clinical acute pancreatitis who had severe acutepancreatitis had a BMI >30, we did not perform a linear regressionseparately in patients with clinical acute pancreatitis. Ourobservations should be considered preliminary and will need confirmationin a larger study. In conclusion, the intrapancreatic fat percentage ispositively associated with BMI and this relationship is similar insubjects with and without acute pancreatitis. The intrapancreatic fatpercentage is also associated with severe acute pancreatitis. Theresults of our study using an appropriate methodology for measuringintrapancreatic fat in acute pancreatitis patients suggest thatintrapancreatic fat may be a potential exacerbating factor in acutepancreatitis, resulting in more severe outcomes. Larger studies andpancreatitis models targeting specifically intrapancreatic fat would beneeded to avoid the deficiencies, and understand the mechanisms of thefindings mentioned above.

6.4 REFERENCES

-   1. Martinez, et al., Obesity is a definitive risk factor of severity    and mortality in acute pancreatitis: an updated meta-analysis,    Pancreatology 2006, 6:206-209.-   2. Papachristou, et al., Obesity increases the severity of acute    pancreatitis: performance of APACHE-O score and correlation with the    inflammatory response, Pancreatology 2006, 6:279-285.-   3. Sempere, et al., Obesity and fat distribution imply a greater    systemic inflammatory response and a worse prognosis in acute    pancreatitis, Pancreatology 2008, 8:257-264.-   4. Karimgani, et al., Prognostic factors in sterile pancreatic    necrosis, Gastroenterology 1992, 103:1636-1640.-   5. Tsai C J, Is obesity a significant prognostic factor in acute    pancreatitis?, Dig Dis Sci 1998, 43:2251-2254.-   6. Funnel. et al, Obesity: an important prognostic factor in acute    pancreatitis, Br J Surg 1993, 80:484-486.-   7. Johnson, et al., Combination of APACHE-II score and an obesity    score (APACHE-O) for the prediction of severe acute pancreatitis,    Pancreatology 2004, 4:1-6.-   8. Ibrahim M M, Subcutaneous and visceral adipose tissue: structural    and functional differences, Obes Rev 2009.-   9. Park, et al., Visceral adipose tissue area is an independent risk    factor for hepatic steatosis, J Gastroenterol Hepatol 2008,    23:900-907.-   10. Olsen T S, Lipomatosis of the pancreas in autopsy material and    its relation to age and overweight, Acta Pathol Microbiol Scand A    1978, 86A:367-373.-   11. Rosso, et al., The role of “fatty pancreas” and of BMI in the    occurrence of pancreatic fistula after pancreaticoduodenectomy, J    Gastrointest Surg 2009, 13:1845-1851.-   12. Saisho, et al., Pancreas volumes in humans from birth to age one    hundred taking into account sex, obesity, and presence of type-2    diabetes, Clin Anat 2007, 20:933-942.-   13. Schmitz-Moormann, et al., Lipomatosis of the pancreas. A    morphometrical investigation, Pathol Res Pract 1981, 173:45-53.-   14. Mery, et al., Android fat distribution as predictor of severity    in acute pancreatitis, Pancreatology 2002, 2:543-549.-   15. Martinez, et al., Obesity: a prognostic factor of severity in    acute pancreatitis, Pancreas 1999, 19:15-20.-   16. Ghanim, et al., Circulating mononuclear cells in the obese are    in a proinflammatory state, Circulation 2004, 110:1564-1571.-   17. Mathur, et al., Nonalcoholic fatty pancreas disease, HPB    (Oxford) 2007, 9:312-318.-   18. Matsumoto, et al., Uneven fatty replacement of the pancreas:    evaluation with CT, Radiology 1995, 194:453-458.-   19. Kloppel, et al., Chronic pancreatitis: evolution of the disease,    Hepatogastroenterology 1991, 38:408-412.-   20. Kloppel, et al., Pseudocysts in chronic pancreatitis: a    morphological analysis of 57 resection specimens and 9 autopsy    pancreata, Pancreas 1991, 6:266-274.-   21. Schmitz-Moormann P, Comparative radiological and morphological    study of the human pancreas. IV. Acute necrotizing pancreatitis in    man, Pathol Res Pract 1981, 171:325-335.-   22. Sennello, et al., Interleukin-18, together with interleukin-12,    induces severe acute pancreatitis in obese but not in nonobese    leptin-deficient mice, Proc Natl Acad Sci USA 2008, 105:8085-8090.-   23. Pini. et al., Effect of Diet-induced Obesity on Acute    Pancreatitis Induced by Administration of Interleukin-12 Plus    Interleukin-18 in Mice, Obesity (Silver Spring) 2009.

7. EXAMPLE Lipotoxicity Causes Multisystem Organ Failure and WorsensAcute Pancreatitis in Obesity 7.1 MATERIALS AND METHODS

Materials:

All reagents were of the highest purity and were procured fromSigma-Aldrich (St. Louis, Mo.) unless otherwise specified. IL-12 wasfrom Peprotech (Rocky Hill, N.J.), IL-18 was from R&D systems(Minneapolis, Minn.), Orlistat was from Cayman Chemical (Ann Arbor,Mich.). Collagenase (type IV) was from Worthington (Lakewood, N.J.). 7-8week old Female ob-ob (B6.V-Lepob/J) mice, or C57bl6 mice were fromJackson labs (Bar Harbor, Me.) and 150-200 gm Sprague-Dawley rats werefrom Charles river laboratories (Wilmington, Mass.). All animals werehoused with a 12-h light/dark cycle at temperatures from 21-25° C., fedstandard laboratory chow, and allowed to drink ad libitum. These werehoused for at least 1 week to acclimatize before experimentation. For invivo, studies there were 8-12 animals per group. All animal experimentalprotocols were approved by the Institutional Animal Use Committee of theUniversity of Pittsburgh (Pittsburgh, Pa.).

Human Studies:

Collection and Analysis of Autopsy and Clinical Data:

We searched the University of Pittsburgh Medical Center—PresbyterianHospital autopsy database from 1998 till 2008 and identified allpatients who received a postmortem diagnosis of acute pancreatitis. Thediagnosis of acute pancreatitis in all cases was based on gross andmicroscopic appearance at the time of autopsy. Of the 46 acutepancreatitis patients identified who also had pancreas slides availablefor review, we excluded the 19 patients in whom the autopsy report alsomentioned a pathologic diagnosis of chronic pancreatitis and the twopatients who were post Whipple resection for pancreatic cancer to avoidthe changes that would occur secondary to these pathologies and do notcontribute to mortality in acute pancreatitis. An additional patientwith acute pancreatitis whose slides showed severe hemorrhage andexcessive autolysis was excluded since this would have precluded anaccurate histological assessment. Thus, the total sample size for acutepancreatitis patients was 24. From the remaining patients in the autopsydatabase, we randomly chose 50 subjects without pancreatitis as controlsfor this study. There was no significant difference in age, sex or BMIbetween these or AP cases (Table 1). The slides of all patients andcontrols were retrieved and reviewed. The study was approved by theCommittee for Oversight of Research Involving the Dead and theInstitutional Review Board at the University Of Pittsburgh MedicalCenter.

The electronic medical records of patients with an autopsy diagnosis ofacute pancreatitis were reviewed to assess whether a subject metclinical criteria for acute pancreatitis (serum amylase or lipase ≧3fold upper limit of normal, typical abdominal pain or radiologicfindings to support the diagnosis) and to assess the severity acutepancreatitis (defined as presence of single or multisystem organ failureattributable to acute pancreatitis, a mention of necrotizingpancreatitis on computed tomography report, or “widespread”, “extensive”or “diffuse” necrosis noted at the time of autopsy). Of the 24 patients,13 met the clinical criteria for acute pancreatitis. Of these, 1 patienthad all 3 criteria (pain, abnormal CT, increased enzymes); 7 patientshad 2 criteria (abdominal pain and increased enzymes in 3 patients andCT abnormalities with increased enzymes in 4 patients); 1 had a clinicaldiagnosis of acute pancreatitis listed on his hospitalization records; 3were sedated/comatose on ventilator support when elevated pancreaticenzymes (>3fold increase in amylase/lipase) were documented (last weekbefore death); and 1 patient was diagnosed based solely on elevatedpancreatic enzymes (this patient also had hypercalcemia during hospitaladmission). Of the 13 patients, 5 had severe acute pancreatitis based onlocal complications (“extensive necrosis” or “severe necrotizingpancreatitis”, “pancreatic hypoperfusion” mentioned on CT scan, 3patients; “diffuse” or “extensive” necrosis noted at the time ofautopsy, all 5 patients). All 5 patients had acute respiratory distresssyndrome, with 4 patients in MSOF, and 4 patients with no previoushistory of renal disease having an elevated serum BUN and creatinineattributed solely to acute pancreatitis.

The remaining 11 patients did not fulfill the clinical criteria foracute pancreatitis. Nine of these did not have serum amylase or lipaseestimation in the 2 weeks prior to death. One patient had a 2-foldelevation 3 days before death (patient had history of alcohol abuse andcirrhosis), and 1 had normal enzymes 5 days before death. CT abdomen wasdone in only 1 of these 11 patients 9 days before death and was normal.Eight of the patients were on ventilator support 5 or more days beforedeath. Of the remaining 3 patients, one had a history of alcohol abuseas described above, one had septic shock and was on the ventilator for 3days prior to death (autopsy revealed focal fat necrosis and moderatecongestion), and one died of cardiogenic shock in a background ofsystemic lupus erythematosus (autopsy revealed mild acute pancreatitis).In none of these was pancreatitis thought to be an immediate cause ofdeath. In 1 of the 11 patients, acute pancreatitis was reported as anunderlying cause of death. This patient was status post-kidney-pancreastransplant, was on a ventilator for 20 days, and had pulmonary embolismas the immediate cause of death.

For histologic evaluation, we retrieved all hematoxylin andeosin-stained slides of the pancreas (1-4 in number) of control andacute pancreatitis patients. A trained pathologist with specificinterest in gastrointestinal pathology blinded to demographic andclinical data examined the slides. Adipose tissue with large vessels andnerves not bounded by at least 2 pieces of pancreatic parenchyma wasregarded as peripancreatic and excluded. The remaining adipose tissue,necrotic fat (bluish cheesy appearance of adipocytes), necroticparenchyma, and parenchymal necrosis immediately contiguous to areas offat necrosis (peri-fat acinar necrosis; PFAN) were additionallymeasured. All of these were measured as a percentage pixel area of eachindividual field after excluding dead space using Adobe Photoshop PS.The pixel areas of individual parameters for each case were added. Thefinal number was divided by the number of fields to give a percentagearea for that parameter in the section. For patients with more than 1section, the average of the percentage of intrapancreatic fat for allfields from different sections was chosen as representative for thespecimen. Von Kossa (to study fat necrosis, saponification), TUNEL(Terminal deoxynucleotidyl transferase dUTP nick end labeling), and oilred O staining were done per standard protocol.

Intra-Pancreatic Fat—CT Imaging Analysis:

Patients who had unenhanced abdominal CT scan prior to their death wereidentified. The average time between CT study and death was 12±4 days,with a range of 1-45 days. CT scans were acquired with multidetector CTscanners (4-16 detectors) using a slice thickness of 5 mm. CT imageswere retrieved from the institutional PACS system (iSite 3.5, PhilipsHealthcare) and de-identified by a certified honest broker. A singlereader (A.F.) analyzed the de-identified images using in-house softwareon a Windows workstation. The reader was blinded to the result ofhistologic quantification of intra-pancreatic fat.

Adipose tissue presents with characteristic negative (−150 to −30 HU)attenuation on unenhanced CT images. Thus, the attenuation of thepancreas is expected to decrease with fatty infiltration within thepancreas, just as low attenuation of the liver is associated withhepatic steatosis. Two methods were used for CT quantitation of IPF. Inmethod 1, the attenuation of pancreatic parenchyma was measured byplacing a total of 9 circular regions of interests (ROIs; 1 cm inmaximum diameter) over the head (n=3), body (n=3), and tail (n=3) of thepancreas for each patient (FIG. 11). Blood vessels and pancreatic ductwere carefully excluded from ROIs. The mean attenuation of the 9 ROIswas calculated and used for statistical analysis.

In addition to mean attenuation measurements, using a second method(FIG. 6B), the percentage of fat volume within the pancreas wasestimated by means of a volumetric histogram and local thresholdingmethod. For this, the boundary of the pancreas on all CT imagescontaining pancreatic parenchyma was delineated to segment the entirepancreatic region. A histogram is calculated from the number and theattenuation values of the pixels of the segmented pancreatic region. Thevolume of the pancreas was computed as the product of the pixeldimension and the total count of pixels. The volumetric percentage ofintra-pancreatic adipose tissue was calculated as the percentage of thenumber of negative pixels (<0 HU) to the total pixel count.

Pancreatic Necrosis Surgical Debridement Fluid Analysis:

Surgical debridement fluid from 6 patients with pancreatic necrosis wasimmediately spun at 300 g to remove cellular debris. The supernatant wassonicated and frozen at −80 C for subsequent analysis of non-esterifiedfatty acids (Gas chromatography, described below).

In Vitro Studies:

Harvesting Cells:

Primary acinar cells from wild type mice (C57B6) were harvested and usedas described previously. Viability, confirmed by trypan blue exclusion,was >95%. Primary adipocytes were harvested as described previously andexhibited an appropriate lipolysis response to isoproterenol (Isop, 10μM: FIG. 7). These were used in the individual experiments. Datapresented is representative of 3 or more experiments.

Acinar Culture:

Acinar culture was done as described previously to study inflammatorymediator upregulation.

Acinar-Adipocyte Co-Culture:

This was done in 12-well companion plates with cell culture inserts(FIG. 14). Acinar cells (20 μl pellet volume per well) and adipocytes50,000 cell/ml were suspended in the medium (Krebs Ringer HEPES Bufferwith 10 mM sodium bicarbonate, pH 7.4 and supplemented with 2.0% fattyacid free albumin) using conditions as described previously. Adipocytesand acinar cells exhibit normal behavior (FIGS. 16, 17) up to 6 hoursunder these conditions, as do acinar cells separated after beingco-cultured in the presence of 50 μM orlistat (FIG. 17).

Serum and Medium Cytokine Assays:

These were done for TNF-α, MCP-1, IL-6, resistin, and adiponectin usingthe fluorescence-based capture sandwich immunoassay based on the LuminexFlowMetrix system (Luminex). The Milliplex Mouse Adipokine Panel(7-Plex) 1 kit from Millipore (Billerica, Mass.) was used. Samples wereanalyzed using the Bio-Plex suspension array system, which included afluorescent reader and Bio-Plex Manager analytical software (Bio-RadLaboratories, Hercules, Calif.) at the University of Pittsburgh, CancerInstitute Luminex Core Facility.

Calcium Imaging:

Acinar cells loaded with fura-2AM as described previously on 35-mm glassbottom culture dishes (MatTek corporation, Ashland, Mass.) were imagedon temperature-controlled motorized stage of an Olympus IX81 invertedmicroscope (Olympus America Inc, Melville, N.Y.) with a 20×0.70 NAobjective and a QImaging Retiga EXi CCD camera (QImaging, Burnaby,Canada). Baseline images were taken, and cells with extremely bright ordim fluorescence were omitted. Fatty acids (linolenic, linoleic, oleic,stearic, and palmitic, 100-1200 μM final concentration) were added, andcytosolic calcium levels [Cai] were determined by alternate excitationat 340 nm and 380 nm, measuring emission at 510 nm. Pre- and post-imagesusing differential interference contrast were obtained to demonstrateappropriate cell morphology. Image acquisition was with the MetaMorph7.5 Imaging System (Molecular Devices, Downington, Pa.) using theMetaMorph 6.3 software. The 340/380 emission ratio were averaged for7-25 acini per field, with background subtraction. Data presented is amean from separate experiments.

In Vivo Studies:

Pancreatitis Model:

IL12+18 model: There were 8-12 animals in each group. Pancreatitis wasinduced as described previously in 8-10 week old female ob-ob(B6.V-Lepob/J) mice. Briefly, IL-12 (150 ng/dose/mouse) and IL-18 (750ng/dose/mouse) were simultaneously given intraperitoneally in 2 doses,24 hours apart. Orlistat at reduced dose than previously published (50mg/kg) was administered in vehicle (0.1 ml 30% ethanol) as describedpreviously. First injection of orlistat or vehicle was 2 hours afterinduction of pancreatitis, and these were then repeated every 12 hours.

Other Methods:

Non-Esterified Fatty Acid Analysis:

The sample was extracted with isopropanol-heptane-hydrochloric acid (1M)(40:10:1, v/v) by vortexing for 25-30 min and allowed to incubate atroom temperature for 10 minutes. Heptane (4.0 ml) and water (2.0 ml)were added, and the tubes were thoroughly vortexed for 5 minutes. Tubeswere centrifuged at 1000 g for 10 minutes at 4° C., and the upper phase(heptane) is transferred into 13×100 mm screw top tubes and dried in aSpeedVac centrifugal concentrator. Non-esterified fatty acids werederivatized with dimethylamine using the Deoxo-Fluor reagent.Non-esterified fatty acid concentrations are measured by gaschromatography separation with flame ionization detection usingheptanoic acid as an internal standard. This derivatization method isvery mild and efficient and is selective only towards non-esterifiedfatty acids so that no separation from a total lipid extract isrequired.

Visceral Fat Triglyceride Composition:

The visceral fat triglyceride composition analysis was done at KennedyKrieger Institute (Baltimore, Md.). Briefly, total lipids were extractedby the method of Folch. The total lipids were weighed and then separatedinto 4 fractions by column chromatography on silicic acid. The secondfraction has the mono-, di- and triglycerides, the non-esterified fattyacids, and ceramides; 400 micrograms of the second fraction was takenand purified, and non-esterified acids, triglycerides, and diglycerideswere collected by thin-layer chromatography on Silica Gel G plates. Thefatty acids were derivatized and analyzed by GCMS as theirpentafluorbenzylbromide esters. ATP levels, cytochrome C release, and %LDH leakage were measured as previously described. Apoptosis wasmeasured by active caspase-3 [western blotting, activity assays(Enzcheck, Invitrogen, Carlsbad, Calif.)], TUNEL assays, and Hoechst dyenuclear incorporation (8 mg/ml Hoechst 33342 added for 15 minutes aftertreatment). Apoptotic cells exhibited fragmented or condensed nuclei,whereas necrotic cells did not have significant nuclear changes or hadslightly swollen nuclei. Results were reported as % of cells with givennuclear changes. These were counter stained with PI (1 μM) to stainnecrotic cells (FIG. 7A, B, C) and imaged with a Zeiss Meta dualfluorescence confocal microscope. PI-positive cells were counted as lateapoptosis or necrosis. Decreased ATP levels suggested necrotic celldeath. Autophagy was studied by western blotting for LC3-I and II. RNAwas extracted using Trizol (Invitrogen, Carlsbad, Calif.). mRNA levelsof TNF-α, CXCL1, and CXCL2 were measured as described previously usingreal time-PCR performed on an ABI Prism 7000 Sequence Detection System(Applied Biosystems, Foster City, Calif.) on proprietary Taqman GeneExpression assay reagents (Applied Biosystems). Mitochondrial complexassays and citrate synthase assay were done as described previously.

Statistical Analysis:

Continuous data are presented as mean±standard error of mean (SEM) andcategorical data as proportions. Bivariate comparisons for continuousdata were performed using the Student's t-test or Pearson correlationcoefficient, and categorical data were compared using the chi-squaredtest or Fischer's exact test as applicable. Subjects with a BMI of <30were classified as normal/overweight while those with a BMI of ≧30 wereclassified as obese. We used linear regression analyses to determine thefactors predicting intrapancreatic fat percentage. In these analyses, weused age (years), BMI (as continuous variable), and disease status(control or acute pancreatitis case) as independent variables. Nocollinearity was detected on data analysis. A two-tailed p-value of<0.05 was considered as significant. The data were analyzed using SPSSversion 17 software, Chicago, Ill.

7.2 RESULTS

IPF in Obesity Worsens Pancreatic Necrosis:

Intrapancreatic fat (IPF) levels were found to be positively correlatedwith BMI irrespective of disease state (FIGS. 6A and 3), as determinedby histological assessment or by abdominal CT scans (FIGS. 6B and 11).Patients with SAP had higher BMIs (FIG. 5A) and IPF (FIG. 6A).Pancreatic sections obtained during autopsies of AP patients revealedthat pancreatic necrosis occurred predominantly around areas ofintrapancreatic fat necrosis (FIGS. 6C, 6C′, 6D, 6E, 6F). Obese and SAPpatients had more fat necrosis (in quadrangle, staining blue on H&E(FIG. 6C′) and dark brown (FIG. 6C) on Von Kossas) and higher peri-fatacinar necrosis (FIGS. 12, 6C, 6C′ 6D, 6E, 6F) than non-obese or mild APand control patients respectively. These changes were unlikely to be apostmortem artifact since autopsy specimens from control patients hadinsignificant amounts of fat necrosis and acinar necrosis (FIGS. 6D, 6E,6F, 14). Further support for these changes being antemortem was providedby the finding of CD68-positive macrophage infiltration around fatnecrosis but not normal fat (FIG. 13). Von Kossa staining revealed areasof fat necrosis and surrounding peri-fat acinar necrosis to be rich incalcium, suggesting saponification (dashed ovals, FIGS. 6C, 6C′) ofNEFAs released into the parenchyma. Measurement of NEFA levels inpancreatic necrosis debridement fluid from 6 SAP patients all of whowere obese (mean BMI; 36.7±4.7) showed a mean concentration of 7.8±2.9mM of which 75.3% were unsaturated fatty acids (FIG. 6G), with NEFAconcentrations as high as 65 mM being present in debridement tissuehomogenates.

Lipolysis Regulates Necrosis, Resistin Levels:

Disruption of the apically directed polarized trafficking results inbasolateral leakage of enzymes and other macromolecules duringpancreatitis (11 (reference 11, listed in section 7.4 below)). Sincethis macromolecular diffusion may play a role in fat-induced acinarnecrosis, we simulated the pathological leakage by co-culturingadipocytes and pancreatic acini (FIG. 14). There was no contamination ofone cell type by the other. When individually cultured, each cell typeappeared morphologically and physiologically normal. However, co-cultureresulted in acinar cell necrosis as evidenced by propidium iodidepositivity, drop in ATP levels and cytochrome c leakage (FIGS. 7A-F) inthe absence of increased active caspase-3 or increase in LC3-II (FIG.15). These changes in acinar cells were accompanied by a large increasein NEFA concentrations (FIG. 7G) and resistin in the medium (FIG. 18),which was similar to that observed in debridement fluid (FIG. 6G) andserum, respectively, of patients with severe AP7. All of these changesin acinar cells were completely prevented by inhibiting lipase usingorlistat (50 μM), which restored acinar cell viability and function tocontrol levels (FIGS. 7C-G, 16, 17, 18).

UFAs Induce Necrosis and are Proinflammatory:

To determine the fatty acids causing acinar cell necrosis in co-culture,we exposed acinar cells to individual fatty acids at concentrations lessthan or equal to those in co-culture or debridement fluid. Intracellularcalcium levels increased with unsaturated fatty (FIG. 8A), which camefrom an intracellular pool since it was inhibited by thapsigargin, butnot by the extracellular calcium chelator EGTA (FIG. 8B). UFAs alsocaused LDH leakage into the medium (FIGS. 8C, 19A). Both the LDH leakageand intracellular calcium increase were dose dependent (FIGS. 8C, 19B).Chelation of the intracellular pool with BAPTA partially prevented LDHleakage and cytochrome C release although this protection was notsustained beyond 3 hours (FIG. 20). Linoleic acid (300 μM) but notpalmitic acid (1200 μM) inhibited mitochondrial complexes I and V (FIGS.8D, 8E, 21), causing a drop in ATP levels and necrotic cell death (FIG.22). Additionally, sub-lethal concentrations (200 μM) of linoleic acid(which increase cytosolic Ca) but not palmitic acid increased acinarmRNA levels of TNF-α, and the neutrophil chemoattractants CXCL1 andCXCL2 (FIGS. 8F, 8G, 8H).

Lipolysis Contributes to Pancreatic Necrosis:

Ob/ob mice developed pancreatitis in response to IL12 and 18 that wasassociated with an increase in serum amylase and lipase levels (FIG.23). Pancreata of ob/ob mice contained 26±2.1% fat. Von Kossa stainingrevealed areas of fat necrosis, saponification (FIGS. 9A, 9F) andsurrounding peri-fat acinar necrosis (FIGS. 9A′, 9G) to contributesignificantly to total acinar necrosis (FIGS. 9A′, 9E). Grossly,pancreata of mice with pancreatitis had saponification, seen as chalkydeposits (FIG. 9B), which also were scattered throughout the fat in theperitoneal cavity (FIG. 9C) with associated hypocalcemia (FIG. 9D).Orlistat treatment significantly blocked all these changes observed inob/ob with pancreatitis on gross (FIGS. 9B′, 9C′), histologic (FIGS.9A′, 9E, 9F, 9G) and biochemical (FIG. 9D) evaluation.

Lipotoxicity Results in MSOF:

Evaluation of the triglyceride composition of visceral adipose tissueshowed UFAs to be significantly increased in obese mice (73% vs 48%,p=0.003) compared to lean mice (FIG. 10A), with a corresponding decreasein SFAs. Pancreatitis resulted in a significant increase in serum UFAlevels and mortality, both of which were significantly reduced inorlistat-treated animals (FIGS. 10B, 10C). SFA levels were notsignificantly reduced by orlistat (FIG. 24). End organ damage in ob/obmice included renal failure with high BUN levels (FIG. 10G), renaltubular vacuoles (FIGS. 10D1, 10D2) positive for fat on oil red O (FIG.10E1, 10E2), tubular apoptosis and injury (TUNEL positive, FIGS. 10F1,10F2), mitochondrial swelling and saponification (FIG. 25A-D). Tubulardamage was also noted in autopsies of SAP patients with acute renalfailure (FIGS. 25E, 25F). All of these changes were normalized in theorlistat treated animals (FIGS. 10D3, 10E3, 10F3) to levels similar tocontrols (FIGS. 10D, 10E, 10F). Lung injury, similar to oleic acidinfusion induced injury (12); manifested as increased apoptotic cells(FIGS. 10H, 26B, 26C) and lung MPO levels (FIG. 10I) were alsosignificantly reduced in the orlistat treated group (FIGS. 10H, 10I,26D). Furthermore, orlistat also normalized serum resistin, TNF-α, MCP-1and IL-6 (FIGS. 10J, 10K, 10L, 10M), suggesting reduction in systemicinflammation.

7.3 DISCUSSION

We show here that local and systemic lipotoxicity contributes tomultisystem organ failure and worse outcomes in obese patients and micewith pancreatitis. We show that these effects maybe due to UFAsgenerated locally that induce necrotic cell death via intracellularcalcium release and inhibition of mitochondrial complexes I and V. UFAsalso upregulate inflammatory mediators at sub-lethal concentrations.Inhibition of lipolysis in vitro and in vivo inhibits resistin andinflammatory mediator generation. Additionally, there was accumulationof oil red O positive vacuoles in renal tubules with mitochondrialswelling, tubular injury and saponification in the kidneys of mice andpatients dying with renal failure. Thus the 2 modes of systemiclipotoxicity seem to be a direct cellular toxicity, and an indirect onevia upregulating other inflammatory mediators (e.g. TNF-α) which mayworsen local and systemic injury independently.

UFAs comprised 73-75% of the human pancreatitis debridement fluid andvisceral adipose triglyceride content of obese mice vs. 48% in leanmice. Therefore, this 1.5 fold UFA increase, combined with the two foldincrease in intrapancreatic fat with obesity (10.4+1.6% in BMI<30 vs.19.4+1.6% in BMI>30, p=0.009) (FIG. 6A) can potentially result in athree fold increase in UFA concentrations when lipolysis is initiated,sufficient to cause local and systemic lipotoxicity. While the increasein serum UFAs with pancreatitis and decrease with orlistat treatmentwere significant (FIG. 10B), the smaller magnitude of these changesnoted compared to other parameters may be due to their saponificationand renal excretion, eventually resulting in tubular toxicity (13).Additionally, the more impressive systemic and in vitro effects oforlistat compared to the local pancreatic effects may be due to itslimited permeability across membranes (FIG. 16), which could havereduced entry into pancreatic tissue.

Our findings have broad relevance since worse outcomes associated withelevated serum NEFAs have been noted in patients with severe burns,trauma, acute pancreatitis and other critical illness (14,15).Interestingly, elevated serum lipase levels and increased serum UFA/SFAratios have also been associated with worse outcomes in these conditions(15,16). Our studies suggest that the UFAs generated from lipolysiscontribute to the inflammation, necrosis, MSOF and mortality in obesityand inhibition of lipolysis reduces all these. UFAs administered throughvarious routes have replicated individual parts of the pathophysiologyof MSOF, further supporting our conclusions. Dettlebach et al notedhypocalcemia and intraperitoneal saponification by intraperitonealinstillation of oleic or linoleic but not palmitic or stearic acid (17).Oleic acid administered intravenously at concentrations found in ourstudy results in ARDS with lung MPO increase and TUNEL positivity (12).Oleic acid and linoleic acid injected into the pancreatic duct inducepancreatitis (18). Similarly UFAs can elevate serum creatinine (17) andcause renal tubular toxicity (19).

TABLE 1 Table comparing the Age, Sex, BMI of autopsy cases (50 controlsand 24 AP cases). Values shown are means ± standard deviation. There wasno significant difference between the two groups. Controls AP p valueAge (Years) 64 ± 16 59 ± 15 0.221 (Mean +/− SD) Sex (F:M) 23:27 6:180.126 BMI (mean +/− SD) 30.2 ± 8.1  33.3 ± 8.5  0.130

7.4 REFERENCES

-   1. A. M. Ghanem, S. Sen, B. Philp et al., Burns 37 (2), 208; A. L.    Neville, C. V. Brown, J. Weng et al., Arch Surg 139 (9), 983 (2004).-   2. D. J. Ciesla, E. E. Moore, J. L. Johnson et al., Journal of the    American College of Surgeons 203 (4), 539 (2006).-   3. H. Oliveros and E. Villamor, Obesity (Silver Spring, Md. 16 (3),    515 (2008).-   4. G. I. Papachristou, D. J. Papachristou, H. Avula et al.,    Pancreatology 6 (4), 279 (2006).-   5. K. A. Porter and P. A. Banks, Int J Pancreatol 10 (3-4), 247    (1991).-   6. P. Heiss, T. Bruennler, B. Salzberger et al., Pancreatology 10    (6), 726; S. S. Vege, T. B. Gardner, S. T. Chari et al., The    American journal of gastroenterology 104 (3), 710 (2009).-   7. A. Schaffler, 0. Hamer, J. Dickopf et al., The American journal    of gastroenterology.-   8. Y. Saisho, A. E. Butler, J. J. Meier et al., Clin Anat 20 (8),    933 (2007).-   9. J. A. Sennello, R. Fayad, M. Pini et al., Proceedings of the    National Academy of Sciences of the United States of America 105    (23), 8085 (2008).-   10. M. Pini, J. A. Sennello, R. J. Cabay et al., Obesity (Silver    Spring, Md. (2009).-   11. G. Kloppel, T. Dreyer, S. Willemer et al., Virchows Archiv 409    (6), 791 (1986).-   12. N. Hussain, F. Wu, L. Zhu et al., American journal of    respiratory cell and molecular biology 19 (6), 867 (1998); J. P.    Lai, S. Bao, I. C. Davis et al., British journal of pharmacology 156    (1), 189 (2009).-   13. L. Hagenfeldt, Clinica chimica acta; international journal of    clinical chemistry 32 (3), 471 (1971); A. Kamijo, K. Kimura, T.    Sugaya et al., Kidney international 62 (5), 1628 (2002).-   14. M. G. Jeschke, C. C. Finnerty, G. A. Kulp et al., Pediatr Crit    Care Med 9 (2), 209 (2008); M. G. Jeschke, D. Klein, and D. N.    Herndon, Annals of surgery 239 (4), 553 (2004); S. Domschke, P.    Malfertheiner, W. Uhl et al., Int J Pancreatol 13 (2), 105 (1993).-   15. K. Sztefko and J. Panek, Pancreatology 1(3), 230 (2001); P. E.    Cogo, G. Giordano, T. Badon et al., Pediatric research 41 (2), 178    (1997).-   16. D. J. Malinoski, P. Hadjizacharia, A. Salim et al., The Journal    of trauma 67 (3), 445 (2009); J. Manjuck, J. Zein, C. Carpati et    al., Chest 127 (1), 246 (2005); C. M. Ryan, R. L. Sheridan, D. A.    Schoenfeld et al., Annals of surgery 222 (2), 163 (1995).-   17. M. A. Dettelbach, L. J. Deftos, and A. F. Stewart, J Bone Miner    Res 5 (12), 1249 (1990).-   18. S. Willemer, H. P. Elsasser, H. F. Kern et al., Pancreas 2 (6),    669 (1987).-   19. D. A. Ishola, Jr., J. A. Post, M. M. van Timmeren et al., Kidney    international 70 (4), 724 (2006); J. H. Moran, G. Nowak, and D. F.    Grant, Toxicology and applied pharmacology 172 (2), 150 (2001).-   20. J. E. Everhart, CE Ruhl, Gastroenterol. 136, 376 (2009).-   21. W. Kimura, F Meyer, D. Hess, T. Kirchner, W. Fischbach, J.    Mossner, Gastroenterol. 103, 1916 (1992).-   22. F. Paye, O. Presset, J. Chariot, G. Molas, C. Roze, Pancreas 23,    341 (2001).

8. EXAMPLE Lipase Inhibitors for the Treatment of Pancreatitis and OrganFailure 8.1 BACKGROUND

Experiments were performed using a model, the technique of which isestablished and well described in rats (1, 2, 4, 7). This involvesinfusion of agents into the pancreatic duct to cause acute pancreatitis(1, 2, 4, 7). We will refer to this technique as “intraductal infusion”.We compared the severity of pancreatic damage and survival of rats afterintraductal infusion of Glyceryl trilinoleate with and without thelipase inhibitor orlistat. In addition, we used a different lipaseinhibitor-cetilistat (3, 6), and studied its efficacy in improvingsurvival of rats in intraductal infusion pancreatitis induced withGlyceryl trilinoleate (GTL).

8.2 METHODS

Male Wistar rats (250-350 gm), were anesthetized. Intraductal infusionof 0.1 ml (n=5) or 0.2 ml (n=5) of GTL (Sigma-Aldrich corporation) aloneor GTL+orlistat (Caymen chemical, Ann Arbor, Mich.) (75 mg/ml, 0.1 mln=5 or 0.2 ml n=5) or GTL+cetilistat (Jinan Wedo Industrial Co., Ltd.,Jinan City, Shandong China) (25 mg/ml, 0.2 ml, n=10) was done asdescribed previously (1, 2, 4, 7). All animals were given pain control(buprenorphine 200 mcg/kg BID), Cefazolin (100 mg/kg), and 10 cc salinesubcutaneously BID as per the IACUC protocol. These were followed forsurvival.

8.3 RESULTS

Gross Pancreatic Appearance:

Intraductal GTL caused severe hemorrhages, and near total necrosis ofthe gland within 24 hours. Orlistat and cetilistat prevented thehemorrhages and necrosis up to 5 days. Representative images from 8 ratsfrom each group are shown in FIG. 27A-C.

Mortality:

All animals with intraductal infusion of GTL without further treatmentwere dead in less than 24 hours (first day mortality 10/10). All animalswith GTL+orlistat survived up to day 5 (day 5 mortality, 0/10). 2 out ofthe 10 animals with GTL+cetilistat died over the 5 day period (day 5mortality 2/10). This is summarized in TABLE 2, below.

TABLE 2 Agent mortality Significance vs. GTL alone GTL 10/10 GTL +orlistat  0/10 P = 0.0001 (Fisher exact test) GTL + Cetilistat  2/10 P =0.0007 (Fisher exact test)

Lung Injury:

GTL treated rats had numerous apoptotic cells present in the lungs atthe time of necropsy. This was shown by TUNEL staining FIG. 29A shows arepresentative lung image from such an animal with arrows pointingtowards the brown staining TUNEL positive nuclei. Orlistat or cetilistatin combination with GTL nearly completely prevented the lung injury asnoted by near absence of such TUNEL positive nuclei at the time ofnecropsy as shown in FIG. 28B and FIG. 28C respectively.

Renal Injury

GTL treated rats had numerous apoptotic cells present in the kidneys atthe time of necropsy. This was shown by TUNEL staining FIG. 29A shows arepresentative kidney image from such an animal with numerous brownstaining TUNEL positive nuclei in the renal tublules. Orlistat orcetilistat in combination with GTL nearly completely prevented the renalinjury as noted by near absence of such TUNEL positive nuclei at thetime of necropsy as shown in FIG. 29B and FIG. 29C respectively.

8.4 DISCUSSION

1. Lipase inhibition with orlistat reduces the severity, preventsmultisystem organ failure and improves survival in mechanisticallydissimilar models of pancreatitis. Our previous study showed thebenefits of using orlistat to inhibit lipases which improved the abovein IL12+IL18 induced pancreatitis(5). With the above data we show itsbenefits in an intraductal infusion model if acute pancreatitis.

2. Inhibiting lipases improves survival in acute pancreatitis. Sinceboth lipase inhibitors cetilistat and orlistat improved survival in thedata shown above, the benefit of lipase inhibition in improving survivalin acute pancreatitis is not agent specific but can be achieved fromusing different pharmacologic agents that inhibit lipases. This lipaseinhibitors as a class of drugs may improve outcomes in acutepancreatitis.

8.5 REFERENCES

-   1. Aho H J, Koskensalo S M, and Nevalainen T J. Experimental    pancreatitis in the rat. Sodium taurocholate-induced acute    haemorrhagic pancreatitis. Scandinavian journal of gastroenterology    15: 411-416, 1980.-   2. Anderson R J, Jeffrey I J, Kay P M, and Braganza J M. Peroxidised    linoleic acid and experimental pancreatitis. Int J Pancreatol 1:    237-248, 1986.-   3. Bryson A, de la Motte S, and Dunk C. Reduction of dietary fat    absorption by the novel gastrointestinal lipase inhibitor cetilistat    in healthy volunteers. British journal of clinical pharmacology 67:    309-315, 2009.-   4. Kataoka K, Sasaki T, Yorizumi H, Sakagami J, and Kashima K.    Pathophysiologic studies of experimental chronic pancreatitis in    rats induced by injection of zein-oleic acid-linoleic acid solution    into the pancreatic duct. Pancreas 16: 289-299, 1998.-   5. Navina S, Acharya C, DeLany J P, Orlichenko L S, Baty C J, Shiva    S S, Durgampudi C, Karlsson J M, Lee K, Bae K T, Furlan A, Behari J,    Liu S, McHale T, Nichols L, Papachristou G I, Yadav D, and Singh    V P. Lipotoxicity causes multisystem organ failure and exacerbates    acute pancreatitis in obesity. Science translational medicine 3:    107ra110.-   6. Padwal R. Cetilistat, a new lipase inhibitor for the treatment of    obesity. Curr Opin Investig Drugs 9: 414-421, 2008.-   7. Zhu Z H, Holt S, el-Lbishi M S, Grady T, Taylor T V, and Powers    R E. A somatostatin analogue is protective against retrograde bile    salt-induced pancreatitis in the rat. Pancreas 6: 609-613, 1991.

9. EXAMPLE Improved Orlistat Formulation 9.1 BACKGROUND

Due to solubility issues orlistat precipitates in an aqueousenvironment, limiting the modes by which it may be administered.Formulations to make orlistat stay in solution in an aqueous environmentare either in free (also called non esterified) fatty acids orpolyethylene glycol. Since free fatty acids are toxic and cause/worsenpancreatitis themselves (Navina S, Acharya C, DeLany J P, Orlichenko LS, Baty C J, Shiva S S, Durgampudi C, Karlsson J M, Lee K, Bae K T,Furlan A, Behari J, Liu S, McHale T, Nichols L, Papachristou G I, YadavD, and Singh V P. Lipotoxicity causes multisystem organ failure andexacerbates acute pancreatitis in obesity. Science translationalmedicine 3: 107ra110) and polyethylene glycol, which also is potentiallytoxic reduces the potency of orlistat, we therefore have developed a newformulation of orlistat which does not have these issues. We also showthat this formulation improves the outcomes in a lethal model ofpancreatitis-caerulin in obese mice.

9.2 METHODS Solution of Orlistat (Called Agent B):

To make 7.5 mls of the orlistat solution (called agent B), 75 mg oforlistat was weighed to which 187 microliters of glyceryl trilinoleate(GTL) was added, and the mixture was gently heated to for 15-30 seconds,with gentle shaking till clear. 3.75 mgs of sodium taurocholate wasdissolved in 7.2 ml saline (phosphate buffered, with a pH of 7.4) in aseparate container. The sodium taurocholate solution was added graduallyin small (about 1 ml) aliquots to the orlistat GTL solution, andsonicated after the addition of one or each of these. This resulted in awhite solution. The solution when spun at 100 g for 2 minutes, did notresult in precipitation of the orlistat and was stable at 4 C for atleast 2 weeks. This solution of orlistat was called agent B.

Solution without Orlistat (Called Agent A).

The solution resulting from the omission of orlistat form the aboveprocess was called Agent A.

Model of Pancreatitis:

50-55 gm ob/ob mice were given an injection of caerulein (50 mcg/kg)every hour for 12 hours on 2 consecutive days.

Treatment Groups (5 Animals/Group):

1. pancreatitis alone2. Pancreatitis with agent A (0.25 ml given intraperitoneally 30 minutesbefore first caerulein injection and 12 hourly thereafter)3. Pancreatitis with agent B (0.25 ml given intraperitoneally 30 minutesbefore first caerulein injection and 12 hourly thereafter)

9.3 RESULTS Mortality:

5/5 untreated animals with pancreatitis died (100% mortality, mediansecond day). 5/5 animals with pancreatitis and agent A died (100%mortality, median second day). 1/5 animals with pancreatitis and agent Bdied (20% mortality, third day). The reduction in pancreatitis mortalitywith agent B was significant (p=0.0476). This is shown in TABLE 3 below.

TABLE 3 P value vs. pancreatitis + condition mortality agent B controls0/8 (0%)  0.3846 Pancreatitis 5/5 (100%) 0.0476 Pancreatitis + agent A5/5 (100%) 0.0476 Pancreatitis + agent B 1/5 (20%) 

Hypocalcemia:

Agent B significantly prevented hypocalcemia induced by pancreatitis. Asshown in TABLE 4 below.

TABLE 4 Mean Serum P value vs. condition calcium (mg/dl) pancreatitis +agent B controls 9.5 0.11 Pancreatitis 4.9 0.005 Pancreatitis + agent A2.9 0.0002 Pancreatitis + agent B 11.8

CONCLUSIONS

1. The proposed formulation of orlistat is stable in aqueous form andefficacious in reducing the adverse outcomes and mortality of a lethalmodel of pancreatitis.2. We have so far shown the efficacy of lipase inhibition in improvingoutcomes in IL12+IL18 induced pancreatitis and GTL induced pancreatitis.The above data is also a third mechanistically distinct model (caeruleinon obese mice) showing the efficacy of lipase inhibitors in thetreatment of severe acute pancreatitis.

Various publications are cited herein which are hereby incorporated byreference in their entireties.

What is claimed is:
 1. A composition comprising a lipase inhibitorcombined with solubility enhancing amounts of a triglyceride form of oneor more fatty acid and a bile salt.
 2. The composition of claim 1 wherethe one or more fatty acid is selected from the group consisting ofoleic, linolenic, palmitic, stearic or short chain fatty acids andcombinations thereof.
 3. The composition of claim 1 where the bile saltis selected from the group consisting of taurocholate, a salt oftaurochenodoxycholic acid, a salt of taurolitholcholic acid, a glycineconjugate or sodium salt of a bile acid, and combinations thereof.